Dressings

Optimum environment for wound healing

1. Moist

2. Free from infection, with minimal slough

3. Free of chemicals and foreign bodies

4. Optimum temperature

5. Minimal number of dressing changes

6. Correct pH

Different dressings are appropriate for different stages of the wound healing

Good wound management necessitates flexible approach to election and use of dressings
Requirements from a dressing

1. Wound

o Protection from infection and trauma

o Debrides, both mechanically and chemically

o Absorbent and removes excess exudate, whilst keeping wound moist

o Maintains temperature and gaseous exchange

2. Patient

o Comfortable and cosmetically acceptable

o Stimulates healing

3. Healthcare provider

o Inexpensive

o Easy to change

Type Description Brand Indications

names

Hydrocolloids Available as pastes, granules, wafers Granuflex Wet sloughly wounds

Mixture of carboxymehtylcellulose,
pectins, gelatins, elastomers
Forms gel on contact with wound
secretions, absorbing secretions

Hydrofibre Consists of carboxymethylcellulose spun Aquacel Heavily exudating

into fibre wounds
Forms gel on contact with wound
secretions, which absorbs secretions

Hydrogels Insoluble polymers, water and Desloughing/debriding

propylene glycol
Absorbs large volumes of exudates and
effective at desloughly/debriding

Semipermeable film Clear polyurethane film coated Not suitable if excessive

dressings adhesive exudate

Alignates Derived from seaweed Kaltostat,

Absorbs secretions to form gel to sorbsan
optimise moist wound healing

Foam dressings Consists of polyurethane / silicone foam Flat / cavity wounds

Very absorbant

Antimicrobial Little evidence for benefit

dressings

Artificial and living Can facilitate cell proliferation,

skin equivalents production of extracellular matrix
Epidermal components - Vivoderm
Dermal components - Dermagram
Composite grafts (epidermal / dermal
components)

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Pain Managment

Analgesic Ladder

1. Paracetamol

1. Analgesia

2. Antipyretic (PGE1) on thalamic temperature centre

3. Liver injury (normally metabolised by P450 and NABQI) if metabolism becomes "super
saturated"

o ?Inhibit prostaglanding production

o Effects

o Antidote: N-acetylecysteine (donates suphydryl groups to form protective glutathione)

2. NSAIDs

0. GI: Inhibit PGE2 + direct effect - dyspepsia, gastritis

1. Renal: ARF - inhibition of PGI2 and PGE2 formation that occurs during situations of
reduced renal perfusion (PGs normally produce vasodilation)
 2. Coagulation: Inhibit TXA2 - reduced ability of platelets to aggregate to form platelet plug,
permanent effect (only overcome by production of new platelets)

3. Bronchospasm: Increased production of Leukotrienes

o Inhibit COX (reduce inflammatory pain-inducing prostaglandins) on arachidonic acid

(from Membrane Phospholipids and Phospholipase A2/Lipocortin)

o Effects

3. Opiates

0. Analgesia - moderate/severe pain

1. Respiratory depression

2. Antitussive (cough depression)

3. Sedation

4. Nausea / vomiting - stimulation of chemotactic trigger zone

5. Constipation

6. Euphoria

7. Histamine release - mast cells: pruritis

8. Increased tone of sphincters (esp sphincter of Oddi - stim contraction of GB; can
exacerbate biliary pain)

o MOA: Effects on Mu and Kappa receptors

o Effects

o Antidotes: - Naloxone (mu receptor antagonist)

4. Local anaesthetics

0. 3-in-1 block (latcut/femoral/obturator) for #NOF

1. Intercostal blocks for #ribs

2. In epidural (extradural space)

3. "float" combination of LA + opiate - normally 0.25% bupivacaine + morphine

4. Used post-operatively for pain; thoracic / upper abdominal surgery

 5. Contraindications - coagulopathy, local sepsis, hypovolaemia (risk of profound
hypotension)

o Local nerve blocks:

o Caudal block

o Epidurals

o Para/Spinal block

5. Antidepressants

6. Neurotransmitter modulators - GABA / carbemazepine

Complementary

1. Hypnosis

2. Cogntive therapy

3. Acupuncture

Incisions & Closures

Purpose of incision

 Access

 Optimise healing

 Good cosmesis

Additional considerations:

 Neurovascular structures below incision line which may be injured

 Previous wounds which may impede blood supply to wound (parallel linear wounds render
separated tissue inschaemic)

 Relaxed skin tension lines

 Avoid multiple cuts into fat (risk of fat necrosis)

Specific Incisions
  Transverse: (1) muscle cutting (2) muscle splitting

 Midline: "incision of indecision" rapid access, minimal blood loss, easy closure

 Kochers

 McBurney/gridiron

 Lanz

 Rooftop

 Paramedian: take longer to form, close, higher risk of blood loss, low complication rate

 Suprainguinal (Rutherford-Morrison)

 Inguinal

 Pfannenstiel

Principles of wound closure

 Edges should be in good apposition (with slight gaping to allow for swelling)

 Wound edges should be everted

 Minimal suture material should be used to secure wound

 Knots should be secure, to one side of wound and easy to remove

Closure options

1. Heal by primary intention

2. Heal by secondary intention +/- VAC, large surface area wounds, large cavitating wounds

3. Delayed primary closure

4. Steri-strips

5. Tissue glue

6. Skin staples

7. Sutures

o Subcuticular - good cosmesis, suitable for clean linear wounds

 o Simple interrupted

o Vertical mattress

o Horizontal mattress

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